Management of PSA Increase from 1.18 to 1.45 in a 70-Year-Old with Family History
For this patient in their 70s with a modest PSA increase from 1.18 to 1.45 ng/mL and a family history of prostate cancer, repeat the PSA test in 1-2 years and continue surveillance rather than proceeding to immediate biopsy, as both values remain well below concerning thresholds and within age-appropriate ranges. 1
Risk Assessment for This Patient
Your patient's PSA values are reassuring despite the family history:
The median PSA for men in their 70s is 1.5 ng/mL, and the age-specific reference range for white men aged 70-79 years is 0-6.5 ng/mL 1. Both of your patient's values (1.18 and 1.45 ng/mL) fall comfortably within normal limits for this age group.
The PSA velocity here is approximately 0.27 ng/mL over an unspecified timeframe. If this occurred over one year, it would be below the age-adjusted threshold of 0.75 ng/mL/year that warrants further investigation in men over 70 1.
Men aged 75 years or older with PSA less than 3.0 ng/mL are unlikely to die from prostate cancer and may safely discontinue screening 1, 2. Your patient's PSA of 1.45 ng/mL places them in a very low-risk category.
Family History Considerations
While the family history is notable, it must be contextualized:
A first-degree relative diagnosed at age 50 does increase this patient's lifetime risk 3, 4. Men with one affected first-degree relative have approximately 2-3 times the baseline risk of developing prostate cancer 4.
However, the cumulative risk calculations that justify aggressive screening (5% by age 60,15% by age 70,30% by age 80) apply primarily to families with two or more affected relatives 3. With only one affected relative, the risk elevation is more modest.
The family history primarily justifies continued surveillance rather than immediate diagnostic workup at these PSA levels 3.
Screening Guidelines for Men in Their 70s
Multiple guidelines converge on limiting screening in this age group:
The American Urological Association recommends against routine PSA screening in men aged 70 years and older or in men who do not have a 10-year to 15-year life expectancy 5.
The USPSTF recommends against PSA-based screening in men 70 years and older (Grade D recommendation), concluding with moderate certainty that potential benefits do not outweigh expected harms 6, 5.
The European Association of Urology recommends against screening for men with life expectancy less than 10-15 years 5.
The key caveat: These recommendations apply to population-based screening, not to management of a patient already undergoing surveillance with known risk factors 2.
Recommended Management Algorithm
Step 1: Confirm the PSA elevation
- Repeat PSA testing in 6-12 months to verify the trend 2, 7. Laboratory variability in PSA testing can range from 20-25%, so a single increase may not be clinically significant 1.
- Use the same laboratory assay for longitudinal monitoring, as PSA assays are not interchangeable 1.
Step 2: Risk stratification based on repeat PSA
- If repeat PSA remains <3.0 ng/mL: Continue annual or biennial monitoring 7, 2. At these levels, the probability of clinically significant prostate cancer remains very low.
- If PSA rises to ≥3.0 ng/mL but <10 ng/mL: Perform digital rectal examination and consider additional testing such as percent free PSA or multiparametric MRI 2, 8.
- If PSA rises to ≥10 ng/mL: Refer to urology for consideration of prostate biopsy, as PSA >10 ng/mL confers a greater than 67% likelihood of harboring prostate cancer 2.
Step 3: Assess life expectancy and comorbidities
- Even if PSA becomes elevated, screening and treatment should only be pursued if the patient has a life expectancy of at least 10-15 years 5, 6. The mortality benefit from screening requires more than 10 years to manifest 5.
- Individualized assessment of health status is necessary; age alone should not preclude treatment if the patient is otherwise healthy 2.
What NOT to Do
Do not proceed directly to prostate biopsy at these PSA levels:
- A PSA of 1.45 ng/mL carries approximately a 1% probability of prostate cancer 7. The risks of biopsy (4% risk of febrile infection, pain, bleeding) 2 far outweigh potential benefits at this threshold.
Do not order multiparametric MRI or additional biomarkers yet:
- Free PSA percentage is primarily useful for risk stratification when total PSA is in the 4-10 ng/mL range 7. At 1.45 ng/mL, these tests add no meaningful diagnostic value.
Do not discontinue surveillance entirely:
- The family history justifies continued monitoring despite the patient's age 3, 4. However, this should occur at reasonable intervals (annually or every 2 years) rather than aggressive short-interval testing.
Key Clinical Pitfalls to Avoid
Overreacting to minor PSA fluctuations: PSA can vary by 20-25% due to laboratory variability alone 1. Always confirm elevations before escalating care.
Ignoring life expectancy: The median age of death from prostate cancer is 80 years 6. For a patient in their 70s, competing causes of mortality become increasingly relevant.
Failing to discuss goals of care: If further evaluation reveals cancer, treatment options carry significant morbidity (1 in 5 men develop long-term urinary incontinence after radical prostatectomy, 2 in 3 experience long-term erectile dysfunction) 6.